Quote for Employee Benefits

Quote Request

Employee Benefits

The form below can help facilitate your request for a quotation on employee benefits. This web form includes all of the information we will need to prepare your quote. It is ideal for small businesses, but it may be cumbersome for larger groups. If you have 10 or more employees, you may prefer to contact us directly in order to provide all of the required information. Thank you.

Request for Employee Benefits Quote

Employer

In the space provided below please provide the name and address of your company, the name, phone number and email of the contact, a brief description of your business, your SIC (if known), your Federal Identification Number (EIN), and the date that you wish your benefits to begin. In addition, please indicate the benefits for which you would like us to obtain quotes.

Employer Name

Street Address

City

State

Zip

Contact

Name

Phone

Fax

Business Information

Business Description

Years in Business

SIC *

EIN

Desired Effective Date

Requested Benefits

Medical

Dental

Life

Vision

Notes

Employees / Family Members

Count

Member Class

First Name

Last Name

Work Zip Code

Birth Date

Gender

Employment Status

Medical Network

Plan Selection

Medical Tier

Dental Network

Dental Tier

Life - Ad&D

Std

Ltd

Vision

Occupation

Salary (Annual)

Add Employees / Family Members Remove Employees / Family Members

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